Provider Demographics
NPI:1245650589
Name:MIRANOV CHIROPRACTIC
Entity type:Organization
Organization Name:MIRANOV CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:MIRANOV
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:580-540-9630
Mailing Address - Street 1:109 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-4117
Mailing Address - Country:US
Mailing Address - Phone:580-540-9630
Mailing Address - Fax:580-540-9631
Practice Address - Street 1:109 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-4117
Practice Address - Country:US
Practice Address - Phone:580-540-9630
Practice Address - Fax:580-540-9631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4061111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty